Provider Demographics
NPI:1174036321
Name:LIEB, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:LIEB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:LIEBOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3065 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3702
Mailing Address - Country:US
Mailing Address - Phone:907-374-1686
Mailing Address - Fax:
Practice Address - Street 1:3065 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3702
Practice Address - Country:US
Practice Address - Phone:907-374-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHYA2771225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant